This article by Michael Carter first appeared on aidsmap.com here.  

Aidsmap.com reports taking HIV pre-exposure prophylaxis (PrEP) does not lead to increased levels of sexual risk behaviour among gay men, investigators from the United States say.

Taking HIV pre-exposure prophylaxis (PrEP) does not lead to increased levels of sexual risk behaviour among gay men, investigators from the United States report in the online edition of the Journal of Acquired Immune Deficiency Syndromes. Numbers of sexual partners fell, as did the proportion of men reporting unprotected anal sex.

“We found no evidence of risk compensation among at-risk MSM [men who have sex with men] initiating PrEP,” comment the authors. “Mean numbers of partners and the proportion of men reporting UAS [unprotected anal sex] decreased significantly from baseline during 24 months of follow-up.”

PrEP is an emerging HIV prevention technology. It involves HIV-negative individuals taking daily antiretroviral therapy to reduce their risk of infection with the virus. In 2010, results of the iPrEx trial involving gay and other MSM showed that daily PrEP with Truvada (FTC and tenofovir) reduced the risk of infection with HIV by 44% overall, with high efficacy seen in people with the best treatment adherence. Although the results of PrEP studies involving heterosexuals have been mixed, the United States Food and Drug Administration approved Truvada for use as PrEP by adults with a high risk of HIV infection.

However, there is concern in some quarters that use of PrEP may lead to increases in sexual risk behaviour. Mathematical models suggest that even modest increases in the proportion of gay men reporting unprotected sex could wipe out the beneficial effect of PrEP at a community level. However, the precise impact of PrEP on sexual risk taking is highly controversial.

Data gathered during a PrEP safety study allowed investigators to explore the impact of PrEP on the sexual risk behaviour of HIV-negative gay men with a high risk of infection with HIV.

A total of 400 men were recruited to the study between 2005 and 2007. All reported anal sex with another man in the preceding twelve months. The study was double blind and placebo controlled. Participants were randomised either to start treatment immediately or to wait for nine months. The men were interviewed at baseline and then every three months about their sexual risk behaviour and use of recreational and erectile dysfunction drugs. The study lasted 24 months.

At baseline, the men reported a mean of 7.25 sexual partners in the previous three months. This fell significantly during follow-up to a mean of 6 partners between months 3 and 9 and a mean of 5.71 partners between months 12 and 24 (p < 0.001). These declines were similar in the immediate- and delayed-treatment arms.

The mean number of reported HIV-positive partners or partners of an unknown status fell from 4.17 at baseline to 3.51 partners between months 3 and 9 and 3.37 partners between months 12 and 24 (p = 0.01). There was also a significant fall in the number of reported partners believed to be HIV negative.

Use of poppers (p < 0.001), erectile dysfunction drugs  (p < 0.001) and a higher perception of the efficacy of PrEP (p = 0.04) were all associated with reporting higher numbers of sexual partners during follow-up.

At the start of the study, 57% of men reported unprotected anal sex in the previous three months. The proportion fell to 48% between months 3 and 9  (p = 0.001) and to 52% between months 12 and 24 (p = 0.03).

The proportion of men reporting unprotected sex between months 3 and 9 was similar between the immediate- and delayed-treatment arms.

There was also a fall in the proportion of men reporting unprotected sex with an HIV-positive partner, from 29% at baseline to 21% between months 3 and 9 and 22% between months 12 and 24 (p < 0.001). Declines in unprotected sex with HIV-positive partners were seen in both the immediate- and delayed-treatment arms.

Factors associated with reporting unprotected sex during follow-up included younger age (p = 0.01), use of poppers (p = 0.02), erectile dysfunction treatments (p < 0.001) and methamphetamine (p < 0.001).

Participation in the study did not lead to an increase in the number of reported episodes of unprotected anal sex, which remained steady between months 3 and 9 and months 12 and 24 in both the immediate- and delayed-treatment arms.

There was a fall in reported episodes of unprotected sex with HIV-positive partners from two in the previous three-month period at baseline to 1.37 between months 12 and 24 (p = 0.05). This was the case for both the immediate- and delayed-treatment study arms.

In contrast, the number of episodes of unprotected anal sex with partners thought to be HIV negative increased between baseline and months 12 and 24 (2.75 Vs. 4; p = 0.01).

“These changes may represent a possible increase in seroadaptive practices, in which men preferentially have more episodes of UAS with assumed HIV-negative partners,” comment the authors.

They also note “men in this study received risk-reduction counseling, condoms and lubricants, regular HIV/STI testing, and linkage to prevention services…which may explain the observed risk reduction and could explain the observed risk declines and could mitigate any potential for risk compensation.”

Despite this, the investigators were encouraged by their results, which they believe “provide important information on changes in risk practices among MSM in the US initiating PrEP in a clinical trial setting”.

Reference

Liu AY et al. Sexual risk behavior among HIV-uninfected men who have sex with men (MSM) participating in a tenofovir pre-exposure prophylaxis randomized trial in the United States. J Acquir Immune Defic Syndr, online edition, DOI: 10.1097/QAI.0b013e31828fo97a, 2013.

This article from This Positive Life by Warren Tong first appeared on TheBody.com here.

How did you find your HIV physician?

The vaccine program that I've been talking about at Vanderbilt, they're really connected with Nashville CARES. As a small business owner, I'd really supported all the events that the organization does every year; I've always been involved in that. I didn't ever think that I'd be a client.

I went over there, and they gave me a list of people; and then I just called around. And I found a doctor. It's been amazing. I think that the physician is kind, is warm, and is also very knowledgeable.

Little things: They said that there's more studies going on about just the neuroscience kind of stuff that goes on with your brain right after you get HIV. I remember during that amount of time, through January and half of February, that there were times I couldn't even remember conversations that I just had. And so there was a short-term memory kind of loss. My physician was able to talk to me about that. Because that's an area where more research is being done. She's always traveling to these conferences, and that sort of thing.

It's been awesome. I have a fantastic doctor! She's understanding, patient, informative, motivating and the best choice for me for treatment. At one of the visits -- you know, when I got to 550 -- I was really aching to discuss treatment. Based on the current numbers, I have made the personal decision not to begin medication -- however, I am also involved in a couple clinical trials that allow me to have access monthly to my viral load and CD4 numbers. Based on this participation and the volume of real-time numbers, I am comfortable making the decision to choose a path that is right for me.

But my hope is that they come out with like a once-a-week kind of pill at some point, because I'm absolutely terrible, even about taking a multivitamin every day. So I've been trying to do better. My physician has given me an exercise, to try to take a multivitamin every day at the same time. She's trying to prep me for when I have to start taking meds. But I'm just hoping that the longer that we wait, as long as my health is OK, or stable, that something new will come out.

How do you think you'll deal with adherence, once you do start treatment?

One thing that I have been real honest about, with all my physicians, is that I am a drinker. I like to have drinks when I go out a couple times a week. I've always been nervous that if I'm supposed to take a pill at 11 and I'm out till 3, whether I'm going to remember when I get home, or when that has to happen. I know there's tons of different little options, and different ways to do it.

But it's just going to be a commitment, once I'm at a position where I need to take medication. I've always been like that. I've never wanted to take any kind of medicine unless I just absolutely had to. But once I'm at that point that I'm going to have to, then it's just going to be a change of priorities. Then I'm just going to make it happen. So I'll probably use every one of those tools.

What do you do to keep healthy?

I eat healthy. I was smoking a pack of cigarettes a day. I've really cut back those. I'm not like a Nazi about it, where I won't ever have a cigarette. I'll have one if I'm out with somebody. But that was really an important discussion with my physician -- that I needed to quit smoking. So that was something that I did. And we discussed openly about me and my drinking. Then they were looking at my blood, and my liver, and making sure everything with that is fine.  

Also, knowing when to say no. If I'm tired -- and there were times that, within that six-month period, I was just kind of tired, and worn out from life. Before I was infected, I would just keep going and keep going. I wouldn't really take care of myself in that way. Now I've really learned how to say no. So if I can't do something, or if I just don't feel like it, for whatever reason, then it's a no.

I know everyone says exercising is important. But I'm not someone that is ever going to go to a gym; it's just always awkward for me to go to a gym. So I'll run. Or it's little things. Like, I live on the fifth floor of my condo, and so I don't take the elevator. I do the stairs.

I don't know if that answers your question. But there's no magic thing, I guess. That's what I'm doing. And I feel good. So . . .

That's good. Little tips here and there always help.

Well, I also think that a lot of what I've gone through is mental, you know? I decided how I was going to attack this disease. I decided how I was going to tell people. And I did it on my terms. Little things used to really bother me. I'm one of those people where everything can bother me. But since January 2012 I just don't let that stuff bother me, you know? If I can't change it then I can't worry about it. So I think that's part of it, too.

I've stayed really connected with things that really encourage me. I love Steve Jobs, so I was reading his book and his quotes. Getting involved with other people online through social media, just talking to them or checking up on them, and that sort of thing -- kind of investing, virtually through the Internet, in some other people's lives, to just check up on them and see how they're doing. It kind of took the focus a little bit off me and made it more about, you know, this is a crusade for everyone that is going through this.

A large part of the reason why I feel I'm doing OK is the way that I just decided to think about things and be positive. I've always laughed when everybody says, "Stay positive," because I'm always, like "Well, I am positive." But now I just said it!

Let's talk about your work. What kind of work do you do?

I'm a talent agent. I own a talent agency in Nashville. I deal with actors and hosts, children and their parents, for television, film, commercials, music videos, print jobs, that kind of thing.

How did you become involved in HIV? You mentioned doing prevention work before your diagnosis. How did you become involved in HIV activism?

Someone doing outreach about the HIV vaccine program approached me at an event at a bar. I really wanted to do it. Before that, there was a well-known female impersonator in town that passed away, and her name was Bianca. Mark Middleton was his name, and the personality was Bianca.

But she was HIV-positive and she was very, very vocal about prevention and the disease. When she passed away, I got my company involved with her memorial. Doing that really got me connected with people that were very sincere and honest and hardworking, when it came to activism and awareness. That's kind of how it started.

And then at one of those events, I saw information about the vaccine study. They said that they needed HIV-negative people that had sex with guys. And in my way, I was thinking, oh, this is so fantastic. This is my way to give back. So I got involved with the study.

From there I started doing some outreaches with them, looking for other volunteers. But I'm actually really glad that I got involved with the vaccine. I want to say this, because some people may wonder: With the HIV vaccine being studied, obviously, it's not a live virus. There's zero chance to get HIV from the vaccine. The way that I got HIV, even though I was in the vaccine study, was because I was exposed to it.

But once I got involved with that, and then Nashville CARES, and helping them raise funds and that sort of thing, I really fell in love with it. Whether people think that it's God or another power or whatever, I really think that it was orchestrated at the right time. Because I really got passionate about it at the same time that it happened to me.

I'd thought I was invincible. Other people have told me that, specifically: "Josh, we never thought this would happen to you. If it can happen to you, then it can happen to me." And that's kind of been their attitude -- which was surprising at first. But when I sat back and thought about it, it's absolutely true. I felt invincible. And so all of that year that I was involved in prevention and activism and that kind of stuff, it really prepared me to be able to tell my story and, now, raise money.

The last couple months I've been involved with some amazing fundraising people. And I'm proud. We've raised a lot of money in the past couple months for Nashville CARES.

Do you ever get sick of thinking or talking about HIV, or do you think you will?

I think I did. I went through a month in the beginning, to be honest, where every week I was doing something related to HIV or awareness or a doctor's office or something. And so in May of last year I kind of got a little tired. And so I just kind of stepped back a little bit. I didn't post any blog, and kind of stayed off Twitter, and even my Facebook.

Now, looking back at that, it was fine for me. It was a little selfish, I guess. What I'm doing is -- and what we're talking about, all of us -- is so much bigger than any individual person or any of our individual stories. We've just got to keep going and keep talking about it. Because the more we talk about it, the easier it becomes to be talked about.

What do you think are the biggest issues that need fixing in HIV today?

One, I think that HIV is not a "one disease fits all." I think there are regional things to think about. I think that people that live out West, in San Francisco, potentially deal with different issues than someone with HIV in Tennessee. I think that that needs to be approached.

After the pastor wrote me that unpleasant email, it really started making me think, why in the South are we having an epidemic, but we also have the highest number of churches? So there's a tremendous opportunity that is being missed in churches with a captive crowd, if you say, to talk about HIV or STDs [sexually transmitted diseases], or any of that. Some churches are against contraceptives or prevention, I guess. My church that I grew up in wasn't. They were OK with birth control and condoms. But they never talked about sex or disease, or any of that.

And so I think the first thing is to look regionally, maybe, at potential issues. And that's what I've been kind of looking at. I can't speak for anyone else in the country, except, you know, Nashville, or the South, really. Here, the stigma is very strong, still. And I was nervous about that.  

Because we're not talking about it enough, in my opinion, in the South -- HIV and prevention and even early on in schools, besides mixed in with every other STD that you can get -- what I think that it's doing is that it's making it harder to talk about later. When I was growing up, I don't really ever remember talking about HIV or STDs, beyond the one day in health class.

And the way to combat stigma: I was sitting in a group therapy, right after I was infected. Maybe I was a little bit green, and maybe the gentlemen that were in there who have had HIV for years, maybe they were a little bit jaded. But in that group therapy that I was in we talked about stigma. And they kept bringing up stigma, that it's so terrible and hard.

And then I just asked a simple question, but it really was a little bit of an epiphany to me before I released my blog. They said the stigma was so bad. And so my follow-up was, well, what have you guys done to combat it? What have you done to fix it? And almost everyone in the room said that they hadn't told anyone that they had HIV. Again, understand some people -- maybe a majority of people -- can't disclose it. I get it. With me, I could.

What was just an epiphany to me: The only way to attack stigma is to talk about HIV, and to talk about it in its face, and show that it's OK. And so those two things, the regional thing and really just keep on talking about HIV, because by doing that, it will become a little more accepted -- not accepted that you want to get it, or that it's OK that people have HIV, but that it's not a death sentence, and that we're not the scum of the earth because we have HIV.

Could you compare how you felt about having HIV when you were first diagnosed, as opposed to now? How has it changed?

I think it has changed. Right after I found out, I was very scared of what people would think. I knew that it wasn't a death sentence and that I would get on the medicine and that though my life expectancy may be shorter than if I was negative, that I would live a long, great life. But I was scared about if someone would love me, and I was scared about what people would say about me.

Right after that, I made a decision that if someone wouldn't love me romantically because of that, that I was OK with that. And I really meant that. I would rather talk about it, about this disease, and attack the stigma, than worry if someone is going to love me, or want to be with me the rest of my life. Because I will be fine.

But coming now, several months later, I respect and I understand the disease a lot more. So my attitude toward that has changed. The thoughts that have started going through my mind now are, you know, disclosure. Why is disclosing or not a criminal act? My mind has just started going down that road. It's not something that I'm going to focus on, but it's just starting to get into the sub-issues; after you get over the big issue of having HIV, it's just how to live with it, you know? Knowing when or not to disclose, or why people choose not to.

But I'm not scared for my life like I was right after I found out that I was positive.

How do you think having HIV has changed you?

It has made relationships that I have with people, in general, more important. It's humbled me tremendously. I mean, I was a cocky bastard. Last year and before that, I was a talent agent and was cocky, and cared less about people and more about myself. This disease really humbled me. I couldn't think of anything worse than contracting HIV, before I contracted it. That was the worst thing in my mind that could happen to me, as a gay man. And then when it happened, it was very humbling.

It was humbling to know that I had to reach out to people to help me, that I needed to go to a therapist and that I needed some of those services that Nashville CARES has provided, that I have supported for years but never thought I would use. So it was humbling, in that aspect.

The other thing is that -- and I don't know if you've heard this before, or what -- but after I found out that I was HIV positive, it made my life a lot richer. Things that don't matter do not matter. Little things don't make me go crazy like they used to. Relationships mean the world to me. My family: It got me even closer to them. So in a weird way it kind of refocused my life into being better.

It's really hard to explain and put that to words, but my life is totally different, in the way that I look at people and relationships; and how I even look at myself is a lot different. I mean, it took a while for me to really be OK with looking at myself in the mirror right after I found out that I was positive. I'm OK with that now. And I feel good about myself. 

What advice would you give to someone else who has just found out they are positive?

If they just found out that they're positive: One, that they are the exact same person they were the hour, the day, the year before they found out that they were positive. That they are still them. Now they just have something that is going to make them choose relationships more carefully and, really, how things are going to be valued.

The one suggestion that I would give is find at least one person that you feel that you can trust, and tell them. Don't try to do this by yourself. Whether it's a therapist, or somebody that truly loves you in this moment. Try to find at least one person to tell that you're positive.

Get online, create an anonymous Twitter account, and find other people like me that are able to talk about it, that you can communicate with, and that it's safe. If you email me anonymously then I'm going to respond. And I won't know who you are but you at least start that chat.

Read TheBody.com. Gosh, I've spent hours on the website. Learn as much as you can about HIV.

But the main thing is that you're still you and that the way that you think about yourself is as important as getting treatment for the disease.

Do you have any closing thoughts, or any takeaway messages you want to relay?

Yeah. First, thank you so much for asking me to just chat with you. Everyone knows their own personal story of the moment they found out that they were positive; and maybe they even have stories like mine, where they know the person that infected them, or that exposed them.

But what you guys are doing is simply amazing. And I know that the three weeks when I was not sure if I was positive or not, I did more research than I'd ever done about HIV. And it's websites like you guys' that I came to, and that I learned the information. And I heard other stories, and I was reading about people. And so, thank you. You know? You helped me tons.

That makes me feel very proud. Thank you for the kind words!

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The Canada-wide survey Male Call interviewed 1,235 men who have sex with other men  (MSM)  - and the results have now been published. It’s been described as “one of the most innovative, ambitious and comprehensive studies ever of this demographic.” It contains quite a few surprises.                      

Why the survey? “Men who have sex with men are the most  vulnerable to HIV, and yet – until now – a clear sense of the attitudes, opinions,and behaviours of many in this group have been missing',” says Dan Allman, Assistant Professor at the University of Toronto’s Dalla Lana School of Public Health. “With responses from both rural and urban areas, in all regions of the country, our survey provides new directions for health policies and programs that can serve this group, prevent further HIV infection and improve overall health and well‐being”.           

The Male Call Canada telephone survey captured mens’ attitudes, opinions and behaviours on topics such as sexual identity, homophobia, general and mental health, condom use, HIV testing and disclosure, the criminalization of HIV and transactional sex. By employing a method in which respondents chose when and where to anonymously call into a toll‐free telephone line, researchers were able to collect responses from men aged 16 to 89, and from an impressive 40 per cent of Canadian postal codes.

The campaign had a celebrity endorsement. PositiveLite.com interviewed gay soccer player David Testo who gave his name to promoting the campaign in January 2012 – you can read my interview here. Testo’s involvement apparently generated a huge upswing in the number of respondents.

The Male Call website contains a series of attractive fact sheets  (designed incidentally by poz Toronto artist Raymoind Helkio, who also designs for PositiveLite.com.) The fact sheets make for fascinating reading, or those with more time can go to the full report here.

In one of the more startling revelations, 49% of men surveyed agreed with the statement “I would not have sex with a man who is HIV-positive even if I am very attracted to him.”

Here are some other fascinating tidbits . . . 

On casual sex, 67% of MSM surveyed reported having had some in the last six months.  How much?  6% of men reported 20 or more partners in that same period, 18% had 6-19 partners, 37% had 2-5 partners, 22% had only one casual sex partner and 17% had none.  52% of partnered men reported having casual sex.

Attitudes to Condoms

Here’s what people agreed with . . 

• The benefits of using condoms outweigh the disadvantages 88.1%
• I would only have anal sex with an HIV positive man if we used condoms 69.4%
• It feels good to wear a condom because I feel safe 67.8%
• I feel guilty when I don’t use a condom 57.7%
• Condoms make sex less pleasurable 48.6%
• The intimate act of giving or receiving cum is lost when using a condom 48.4%
• When a person brings out a condom I feel physically aroused 32.1%
• Safer sex is less important now that HIV treatments are available 10.2%

74.8% of Male Call participants had been tested for HIV and 34.5% of participants had been tested in the previous six months. 6.6% reported having HIV, 26.2% reported they were unaware of their status.

Expectations

Male Call participants were asked “When is the best time for an HIV-positive man to disclose his HIV status to a new sexual partner?”

• before any penetrative sex (e.g. oral or anal) without a condom 56.2%
• when they first meet 25.9%
• before any non-penetrative sex (e.g. mutual masturbation) 11.9%
• before any penetrative sex (e.g. oral or anal) with a condom 0.9%.

Knowing a Partner's Status

These question relate to the importance of knowing a partner’s HIV status  before engaging in the following sexual acts

• 96.3% before unprotected anal sex.
• 84.4% before protected anal sex.
• 75.4%  before oral sex.
• 43.3% before mutual masturbation

Shared Responsibility

• 98.4% agreed that both sexual partners are equally responsible for preventing HIV transmission.
• 87.4% agreed with the statement “In order to know a partner’s status for certain, it is an individual’s responsibility to ask his partner his status.”
• 49.0% agreed with the statement “I would not have sex with a man who is HIV-positive even if I am very attracted to him."

Positive men

Turning now to the questions pertaining to HIV-positive men, 88% of HIV-positive participants rated their mental health as good to excellent. 87.3% rated their physical health as good to excellent.

68.3% of HIV-positive participants slept less than 8 hours per day. Only 31.7% reported 8 hours of sleep or more.

What do HIV-positive participants worry about? I worry about, they say...

• Being discriminated against and stigmatized because of HIV.82.5%
• Being rejected by gay and bisexual men in my community because I am HIV-positive 67.7%
• The fear of being prosecuted by someone for not disclosing that I am HIV-positive 51.6%
• Not understanding medical information about HIV 30.2%

On the issue of criminalization, the survey generated headlines like this one from the Sun and this one from the Globe and Mail because it appeared to find a large number of men who supported criminalization. In fact 83% of all men indicated non-disclosure before anal sex should be a crime, with 42% believing failure to disclose is criminal in the case of oral sex, while 17% opposed criminalization of non disclosure in any circumstances.

Here are some more disturbing numbers, straight from the report . . 

The Globe and Mail Story headlined with the worrisome title “HIV-AIDS non-disclosure should be a crime, study of gay and bisexual men finds.“  However the news is not all bad. PositiveLite.com asked Richard Elliott, Executive Director, the Canadian HIV/AIDS Legal Network, for a comment.  Here’s what he said:

“Unfortunately, some important details of the Male Call study about HIV and men who have sex with men got lost in summation and a simplistic headline (“HIV-AIDS non-disclosure should be a crime, study of gay and bisexual men finds”, Apr. 11).  The result, I fear, is to simply perpetuate some knee-jerk and widespread stigmatizing attitudes about people with HIV and unjust applications of the criminal law.

"The study data in fact showed the following: men were virtually unanimous in supporting early disclosure of HIV and a strong majority expected a casual sex partner to disclose if he has HIV, but they were also virtually unanimous in agreeing that there both partners have equal responsibility for HIV prevention. Less than one-third of study participants thought criminal prosecutions for not disclosing HIV status are effective public policy when it comes to preventing the spread of HIV. In fact, the study data suggest public health harms: 62% think that criminal prosecutions increase stigma and discrimination against people with HIV, close to half agree that such criminalization deters people from seeking HIV testing and indeed 18% agreed that, given the current legal context of possible prosecution, it’s better not to get tested for HIV.

"But perhaps most significantly, the headline seriously oversimplifies the issue in suggesting that the strong majority of gay men and other men having sex with men support criminal prosecution for HIV non-disclosure. In fact, only 42% held this view without qualification. An equal number felt criminalization is not justified in some circumstances. Of these men, 70% said there should be no prosecution in cases where a condom is used – a sensible position that, regrettably, the Supreme Court of Canada rejected in its most recent pronouncement a few months ago. Similarly, 58% think criminal charges for not disclosing are not warranted in cases of oral sex. These more nuanced views quite properly reflect the available science we have about the exceedingly low risks of HIV transmission in such circumstances."

Remember that time you went to that awesome restaurant, ordered a fantastic meal, everyone enjoyed it, then you realised at the end you didn’t have the money for to pay for it?  No? 

OK, how about that great drive up the coast you always wanted to do? The people you met, the things you saw, everything was awesome – but you ran out of petrol three-quarters of the way there. Had that happen?

These are metaphors, of course.  I like using them, as well as satire, which often leaves readers dazed, confused, and thinking I’m a wanker.  I also stray off the point from time to time.

So here it is:

This will be the last Bipolar Bear blog entry. I don’t know if I will start up again at this stage. Some of my reasons will be clear by better explanation of the metaphors above.

Firstly, my grandmother is dying. This is the second close family member to go in under a year and, as I alluded to yesterday, it’s time to focus on the things that matter.

Second, there isn’t enough of me to go around. Much as I get a great deal out of writing and interacting with you all through this medium, I’m starting to get tired – literally. I often sleep through entire weekends. Other things, besides family, are demanding my attention in a way I can no longer ignore.

This blog began as a part of my work at the Mental Health Foundation in New Zealand. Indeed it was publicly supported as such. A year later, there was debate within the organisation as to whether a blog dedicated to gay men’s mental health and wellbeing fitted with the Foundation’s work.  Similar debates were had around the project that was to become my documentary, “Men Like Us”.

I left the organisation and funded the completion of “Men Like Us” personally – this is nothing new to me, all but one of my films have been paid for out of my own pocket.  The result was better than I could have imagined – apart from the high-profile and excellent blockbuster doco “Untouchable Girls” – it’s the only gay-themed documentary from New Zealand to ever be released in cinemas, and receive glowing reviews from critics and viewers alike. That’s a testament to the power of the nine men’s stories contained within it.

While I continue to believe there is immense social value in films by and about gay men, there is not a great deal of financial value in them in terms of profit.

The cost of completing “Men Like Us”, supporting it through a theatrical release in New Zealand and getting it onto television, and subsequently onto DVD and download are still being recouped.

I have also incurred considerable debt underwriting the productions made by my charitable film-making trust, Number 8 Films, which my co-trustee Andy Jalfon described in Express recently as coming to a natural end.

This is broadly true, in the sense that if you sprint non-stop for fifty kilometres, things will come to a natural end when you collapse on the pavement gasping for breath and needing to be defibrillated.

I’m really proud to have instigated monthly gay film nights in Auckland, which ran at a loss for several months until we convinced a couple of key sponsors to come on board – Get It On and the GABA Charitable Trust. This support was great, as the events could not have been run without it. Cinema hire, film hire and censorship is an expensive business for a niche audience, as anyone who runs a gay film festival will tell you.

The administration of these events, including negotiation with distributors, putting films through the New Zealand censorship process, writing promo copy for media, liaising with the cinema over ticketing and promotion, is time-consuming as well. I continued to do all of this until the film nights ended in February of this year, despite the fact I’ve been living in Australia since August.

So, to quote David Bowie’s fantastic comeback single, where are we now?

We are tired, and we are in debt. We meaning me. I need to recharge my energy and my finances. I need to focus on my family. I need to find new ways of working and expressing myself creatively after being worn down by more than a decade of being surrounded by “no” people; be it “no you can’t do that”, “no we won’t support that”, or “no I haven’t got time to help you”.

I’d like to thank each and every person out there that has enjoyed the writings, the films, the events, have been moved by them, shared them with friends, bought DVDs – all those forms of support which have made it worthwhile to keep going through the tougher periods.

But for now, it’s time to shut the door on the vault and say “game over”.

Then place people I don’t like in a series of elaborate traps in which they’re hacked into Findus lasagne pieces (just kidding).

I trust you will understand.

This article first appeared on Christopher’s own blog here.  

April 15, 2013 - A new study indicates that young men who have sex with men (YMSM) around the world experience higher levels of homophobia, unstable housing, violence, and other factors that hinder access to HIV services, compared to older MSM. Conducted by the Global Forum on MSM & HIV (MSMGF), the analysis shows YMSM fare worse than older MSM in their attempts to access numerous HIV services, including HIV treatment. 

“Existing data indicates that rates of HIV are rapidly increasing among YMSM in low and high income countries alike,” said Dr. George Ayala, Executive Director of the MSMGF. “However, most research fails to disaggregate data focused on YMSM from broader samples of MSM and young people, making it impossible to understand the unique needs of this population. This is the first study to look at these issues among YMSM on a global scale, and the results are alarming.”

The analysis uses data from the 2012 Global Men’s Health and Rights study (2012 GMHR), a multilingual online survey of 5779 MSM from 165 countries, including 2491 YMSM (aged 30 and below). Data from YMSM participants was examined to assess levels of access to HIV services and factors that impact access to services for YMSM. Results are presented in a new policy brief entitled “Young Men Who Have Sex with Men: Health, Access, & HIV,” released today by the MSMGF.

The policy brief reveals that only 33% of YMSM surveyed reported that low-cost condoms were easily accessible, and even lower percentages of YMSM reported easy access to low-cost lubricants (18%), low-cost STI treatment (14%), HIV education materials for MSM (9%), and HIV risk reduction programs for MSM (7%). Of participants living with HIV, nearly half of YMSM with a CD4 count below 350 were not engaged in treatment (44%), compared with 17% of older MSM. Only 38% of YMSM living with HIV reported viral suppression, compared to 73% of older MSM.

Findings also indicate that 20% of YMSM surveyed had no income and 30% had no stable housing, which have both been linked to greater HIV vulnerability and reduced access to HIV services. Compared to older MSM in the 2012 GMHR sample, YMSM experienced significantly higher levels of homophobia and violence. Among all MSM surveyed, homophobia was significantly associated with reduced access to condoms, lubricants, HIV testing, and HIV treatment.

“While homophobia can be damaging to gay men of all ages, it can be particularly harmful to younger gay men,” said Daniel Townsend, MSMGF Steering Committee member. “Like many young people, they often have no income and depend on family for housing. If their family does not understand or accept their sexuality, they risk ending up on the street. Without stable housing or resources, many young gay men face extreme challenges in meeting their basic needs.”

YMSM not only reported greater barriers to HIV service access compared to older MSM, they also reported significantly lower levels of community engagement and comfort with service providers. These factors, along with family support and availability of safe spaces, were associated with increased access to HIV services among MSM of all ages in the 2012 GMHR.

“This data shines light on our collective failure to ensure that YMSM have the resources they need to keep themselves healthy,” said Dr. Ayala. “Moreover, it is a powerful reminder that HIV among MSM is an international development issue, inextricably linked with housing, health, education, and security. Donors and policy makers must treat HIV among MSM of all ages with the same level of urgency afforded to other international development priorities, and they must take concrete steps to ensure that the unique needs of YMSM are accounted for.”

Produced in collaboration with the MSMGF Youth Reference Group, composed of 18 YMSM advocates from 11 countries around the world, the policy brief concludes with a set of recommendations for addressing HIV and its social drivers among YMSM. Recommendations include addressing housing stability and economic dependence, providing comprehensive HIV prevention tailored to the needs of YMSM, improving treatment and care for YMSM living with HIV, taking action to reduce barriers and increase facilitators to HIV service access among YMSM, and supporting YMSM leadership and involvement in the HIV response.

The full policy brief can be found on the MSMGF’s website  here. http://tinyurl.com/br5qn6d.  

This article from This Positive Life by Warren Tong first appeared on TheBody.com here.

How do you start the conversation with somebody when you're disclosing to them?

Well, for me, it's actually been pretty easy. Because I don't know if I copped out. I mean, I posted it on Facebook, and I have a blog. The blog is now at almost 15,000 views. Then being on the cover of the magazine here, locally. Everyone here, as far as the gays in town, they're all aware. I guess some of them are probably tired of me talking about it.

But there's other things that I had to think about. I have a company and I have a staff, and we have interns and that sort of thing. And so I've made it a decision again -- it's not my legal responsibility -- but I made a decision that I was disclosing to everyone.

You know all the pink stuff, the marketing for breast cancer awareness? Susan G. Komen for the Cure? People walk around and they say stuff like, "I'm a survivor of cancer." Or, my mom -- I've done MS Walks with her. And it's very easy for her to tell people that she has MS. I see it real similar, that it's just a disease that I'm fighting. There's no cure yet, and there's no vaccine that works 100 percent yet. So I'm just on a journey, just like other people; but it just happens to be that what I'm fighting is HIV.

It is so important to me for people, and particularly -- and that's where my heart is -- ifor Nashville, because this is my home; I've lived here for 10 years. So it's so important for other people that have HIV that in any way feel like they're scared or feel less or whatever. I want them to know that they're still the same person, that they're OK, and it's going to be fine. So that is really the bottom line on all of it.

The benefit for me, with the way that I disclosed, and that I've told everyone and I've told them so quickly was that I haven't gone to the bar or to the club or whatever here, and knew that people were talking about me, about something that they haven't heard from me about. So I don't feel uncomfortable going out now. And I'm sure there are people that are going to say things. But I've tried to be honest and I've tried to be transparent.

And some people have called me brave, which I don't think at all. I don't think that what I'm doing, or what I've done and what I'll continue to do, is brave. But if it helps one person or two people here feel like they're OK, then that's enough.

A good example of that is I got a call, a couple of weeks after I released the blog, from someone -- and I couldn't even tell you who it is now -- but they called me. It was a 22-year-old here in my city that had just found out a couple days before they called me that they were HIV positive. And they contemplated committing suicide because of it. And they happened to see someone reposting my blog on Facebook and they read it. Then they felt compelled to call me.

From there, I talked to him for just a few minutes. And he said that because of the blog he decided to tell at least one of his friends, or a couple of his friends. So now he's fine, you know? He didn't commit suicide.

I don't think that I had anything to do with that, except that I know that's what people feel, or that's what people have told me that they have felt immediately. And so if my being able to talk openly about how I contracted it, and what I'm going through, and how I feel, and all those things, if that helps other people then it's worth it to me. Because I'm in a position where I can, you know? I have a strong support group around me. My family means the world to me, and they're OK.

I don't think you give yourself enough credit. It sounds like you saved that boy's life. Would you say that's the best response you've gotten from sharing your status?

It's funny, but I have been flooded with different stories of people. And so some of the best responses to me are people that have been living with this disease for 15 years or 20 years, and they come and say, "Thank you. I haven't been in a position where I could really talk about it like you, but thank you. It makes me feel a little bit more normal at least." Just as a whole, that's the stuff that feels good.

But there have also been a couple of bad things. I got a really nasty e-mail from a previous pastor. He told me everything that he thought about why I got the disease, and how I'm living with it, and all that stuff.

Then, you know, there's thedirty.com, which is a funny website. Somebody posted something not pretty about me on there, basically saying that I'm trying to get fame from this, or monetize this. And that's not the case at all. I haven't made any money from talking about my status, and I wouldn't.

But all that is to say that there's good and bad, but the great things have far outweighed any negative that could ever come at me.

What did your youth pastor say to you, and how did you react?

Basically what happened is that I released the blog, and then the pastor saw the blog and sent me a very long email, basically saying that it's unfortunate that I contracted the disease, that he saw the disease as a direct result of me living a sinful lifestyle from my sexuality, and that God really wants to love me, and so I need to repent and turn away from all of this stuff. Just a religious rant. But the hard part for the email was that it was really tied in with some things that were very personal to me that he really used as weapons -- the fact that I had been molested as a kid, and the fact that the pastor's oldest brother passed away from HIV, and that sort of thing.

He was trying to do exactly what he thought was right, which was to email me and tell me that I'm wrong and that I'm sinful. Although I disagree, adamantly, with every theology that he discusses in the email that he sent to me, I really truly believe that his heart was in a place where he thought he was doing the right thing. So I don't hate him or despise him, but I did respond to him via a blog.

I basically just told him that HIV was not a result of God being angry at me, and that eventually I would be in heaven and that I'm OK.

I did rebuke him a little bit, in a nice way. I told him that this was the absolutely wrong email to ever send to someone that's recently infected, and especially someone that's recently infected and then trying to talk about it in hopes of decreasing stigma and also furthering the discussion of prevention in others. This is totally the wrong tone. And so I responded in that way. But I haven't directly spoken or had a conversation at all with that pastor. And I don't really want to.

He sent me the email but I responded to him in the only way that I knew how at the moment, which was via my blog. But I did disguise his identity so hopefully he hasn't gotten any hate mail, or anything.

But, you know, it was totally the absolutely wrong thing to ever say to someone, particularly someone that's recently infected.

Let's talk a little bit about dating and relationships. Has being positive affected your dating life or your sex life at all?

During the three weeks that I was waiting on my results, that constantly came over my mind. I was absolutely scared that I would never be loved again. I felt that maybe that the gays in my town would think that I was used goods. I had already come out of the closet about sexuality, and that had limited the people that would want to date me. And then now that I'm HIV positive I was like, wow, that even makes the pool even smaller. Because I thought that only someone that was HIV positive would even want to date someone, you know, like me. I was real nervous about that.

The other thing that was really hard is that during the middle of finding out, I had met someone that I hadn't been intimate with, but I'd seen him out several times, and was really kind of digging this guy. And the thought of having to tell him that I was positive: I just knew that he would run away. So I was kind of preparing myself for that. 

I didn't actually call him and tell him that I was positive. We hadn't have sex or anything like that, and so I didn't have to tell him anything. But he is a friend of mine on a social media; and so when I released the blog on my Facebook, he saw it. And he actually called me and he said that he wanted to see me. And I said OK. We met, and he told me that it was OK.

I think the coolest thing that could ever happen for someone that is positive is if someone that is negative just wants to date them. I think that is the coolest thing, and one of the bravest things, in the middle of all this. With that said, of course dating and relationships and that kind of stuff is overwhelming. I mean, when do you disclose to someone? Do you get them to really start liking you before you tell them? Or do you tell them from the very beginning, when they have absolutely zero invested? I don't know. I think that's a question that keeps going. 

Obviously, I've researched and looked online. There are tons of people that only want to hook up with someone that is DDF (or disease-and-drug-free); they would never want to date somebody that was positive. I've seen stuff online, blogs and forums where people are saying that positive people should only date positive people so it will quit happening. That was something that I was really concerned about. It was a decision that I had to make, because I didn't know how he would react, or anyone else would react. But I decided I was OK with being alone the rest of my life if I could talk, if I could tell my story, and if I could in some way decrease the stigma and then further the discussion of prevention. That was more important. And so I had to be OK with that. But it worked out really well for me. So I'm dating somebody that I've been dating for over a year now.

We've already established that on top of that, you also have a very close and supportive family. Did your relationships with them change at all after you disclosed to them?

The only thing that changed was that the first several weeks after I told them that I was positive, they wore me out with phone calls and text messages, asking how I was and how I was feeling, and that sort of thing. So it was appreciated, but I finally had to tell my family: "Listen, you don't always call me every day anyway. So you still be you, and I'm still me. We can talk; but you don't need to ask me every day how I'm feeling, and if things are OK. Because I'm fine." But besides that -- which is, obviously, appreciated -- my family really rose to the occasion and have been amazing supporters for me.

That's wonderful. Can you tell me a little bit about your background? Where did you grow up?

I grew up in West Tennessee, in a small town called Jackson. It's between Memphis and Nashville. A lot of people know Jackson for one reason, really: My hometown has gotten hit by tornadoes a lot.

It's a very small conservative town. I never hooked up or anything in my hometown; that would have been way too weird and that sort of thing.

When did you tell your family that you were gay?

I moved to New York right after high school, to go to an acting school. That was the first time that I had voluntarily had sex with a guy -- a terrible experience, by the way -- then I moved back.

I kind of dated a couple people after I moved to Nashville for college. I first told my sister, when I was around 24, that I was gay. And she was fine with it. I hadn't told my mom and stepdad, or my stepmom or my dad, yet.

So I went home one Christmas the year after I told my sister. My mom, again, has MS. We were in the bathroom, and she was getting ready or something. She asked me, "Are you dating anyone? Because I never hear you talk about anyone." And I kind of smiled, and I said, "Yes."

And she said, "OK. Well, do you want to tell me about it?" I started telling her about it. But it was very generic; but still, to me, it was obvious that it was about a guy. So I thought I had come out to my mom.

So she would call me for the next six months, and we would talk about the person that I was dating. But I didn't realize: Because of her medicine she was on, she didn't remember that conversation, and she didn't realize that I'd come out to her. And so for six months, we had talked on the phone and she would ask about whoever I was dating. But it would always be, you know, "How is your friend So-and-So?" And so I just assumed she just wanted to call him friend, which was fine. But she really thought it was a friend.

There was a day that I realized absolutely that it wasn't clear to her that I was gay. And so I had to come out to my mom a second time, which is funny.

How I came out to my dad is, I had called my stepmom. I told her. And I told her to tell Dad. An hour later he called me and asked me if I needed to tell him anything. And I said, "Nope. You probably know everything."

He said, in his Southern way -- he's a fisherman; he's a tire salesman -- the nicest thing that he could say was: "You could kill someone and I'd still welcome you into my house." Which makes other people laugh; but that's totally my dad's character. So I knew it would be OK.

But since that time my sister has come to visit; I've taken her out to the gay bars and she obviously has met who I was dating and that sort of thing. My dad and my stepmom: I convinced him to let me take them to a drag show, and to the gay bar. And they know who I'm dating, and who I've dated. My mom is the same way. It's awesome, because it's completely open.

The one thing that's cool now is that my mom sent me a text the other day saying Obama is backing gay marriage. And I was, like, "Yeah. That's really cool."

And she said, "Yeah."

And so I sent her a text message -- something like, "So, are you ready to walk your son down the aisle one day?"

And she replied back: "Absolutely." Which was just a cool text to see from my family. But, yeah. I'm completely out of the closet about my sexuality and, I guess, my status.

When did you know you were gay, yourself? And was that difficult?

It's always a funny question to think through. I remember when I was a kid, and I don't know the age -- 5 seems to be the right one to say -- but I remember playing with the neighbors, the little boy next door; I remember kissing him. And that obviously is not what other kids do.

But also, we lived in a small town. I had girlfriends, and I really liked them. But it wasn't ever where I wanted to go home and sleep with them, or anything. You know, we were just friends, I guess.

What I explained earlier about when I was younger and was molested: That was when I was older. I was, like, 10, or 11, or 12, or something like that. It was a family member. But as far as knowing I was attracted to guys, it was early on. I remember kissing that boy.

Do you want to talk about the molestation at all?

I'm really OK with it now. It was a situation where it was a family member and I was told that this is what guys do, you know, when they're older. And so when I say molested, there wasn't ever anything violent or anything like that. But I absolutely was taken advantage of as a young person. And that should not ever happen by an adult, obviously.

But in the same instance, although I've kind of blocked those circumstances a little bit, the fact was, moving forward, that I don't think that that had any influence on me being attracted to guys.

Do you know what happened to that family member?

No. I told my family and my sister, and then there was a kind of division that happened in the family because of that. Years after -- I think I was 18 when I finally told them what had happened -- there was a lot of anger. I talked everybody down. I said, "I'm really the only one that has the right to be mad, and I'm not mad. I'm fine. And that's that."

The thing is -- I don't want to give too much information -- that some families have uncles that aren't legal yet. So they may be 10 years older, or something. But it wasn't like a fully grown adult.

There was nothing else that needed to happen. I'm completely fine with it. I've forgiven him. I mean, I'm not going to go to dinner with him, probably. I don't go to extended family reunions, anyway.

Let's talk about health care and treatment. What has your health been like since your diagnosis?

January was a total wash for me. I was completely sick, and not feeling great. I finally saw a doctor on Valentine's Day. The reason why my viral load was so high at the beginning, readers may or may not know, is because I found out so soon. It's been remarkable -- and those are the words that physicians have used -- being able to really track my process and my progress, particularly because of the vaccine study. They've had my blood work and have been viewing everything when I was negative, through seroconversion, all the way through now being four or five months into being infected.

It's been interesting. I've had; every two weeks or so, I've had CD4 counts and viral loads, which is way more information that I would ever suggest anyone ever have. But that's just the way that it's worked out between doctor visits or vaccine visits. My viral load came down, and it's come down even more.

I have made the decision right now, in consultation with my HIV specialist, to not begin medication, as my viral load (at last test) was 1,102 and my CD4 count is 730, with great percentages.  

It's important to understand that although I am not on medication, that I consider myself in therapy and in treatment. This discussion of being "on" therapy and "on" treatment leaves out a very attentive, concerned and responsible group of individuals -- like myself -- that, at the given moment, are not taking HIV meds.

Deciding which medication, if any, that I will choose at the exact moment that I feel is best for me, personally, is just that: a personal medication decision I will make based on my body and health, consultation with my doctor, and the current information and research that appears to apply to me. I'm not a one-type-fits-everyone kinda guy. But just because I'm not on medication, doesn't mean I am not taking this as seriously as others.

To be continued . . . 

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